Claim, Greenwood, LisaCLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form in full and attach any additional information that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001. It will then be referred by the City Council to the appropriate department for investigation. Once that investigation is completed, a report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and recommendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: Lisa Greenwood
2. Address: 1925 Jeffrey Drive
3. Telephone Number: 588 9556
4. Date of Incident: 8 10 01
5. Time of Incident: 7:45 a.m.
6. Location of Incident (Be specific): 1925 Jeffrey Drive
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give full details upon which you base your claim. If a City employee was involved, give the employee's name.)
City Employee, Catherine Schiesl, backed City truck into our Chevy Lumina Van causing damage to front of van
8. What were weather conditions like? Clear & Dry
9. Give name and address of any witnesses: -
10. Did police investigate? (If so, give names of officers.) Yes, Benji Young
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.)
Yes, Estimate is enclosed
13. What other damages do you claim, if any?
None
14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name and address of insurance company and amount paid.)
No
15. What amount do you claim from the City of Dubuque?
$316.22 was estimated by Bird Chevrolet - they stated that additional charges may be applied @ the
time of service.
16. Why do you claim the City of Dubuque is responsible?
The City Truck hit our vehicle while our vehicle was parked.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
Dated at Dubuque, Iowa this 10th day of August , 2001
/s/ Lisa Greenwood
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
,qUO-lO-O1 FRI 03:30 PM DUBUGUE CITY CLERK FP~× NO, 563 589 0890 P, 02
12. Was any damage done to property? (If so, desoribe property and the extent of damages,
Attach estimates of damages or describe basis for ascertaining extent of damage.)
13. What other damages do you claim, if any?_
14. Have yeu been compensated, for any part or all of your claim by any insurance
company? (If so, give name and address of insurance company and amount paid.)
15. What amount do you claim from the City of Dubuque? ~/~2Z. /~/~ ~~
16. Why d .
uque Is responsible?
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address,) /~
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
(Rev. 1/00 & 7/01)
(Signature)
(Print Name)
Date.' 8/10/01 04:t8 PM
Estimate ID: 5309
Estimate Version: 0
Preliminary
Profile ID: Mitchell
BIRD CHEVROLET
3255 UNIVERSITY AVE. P.O. BOX 57 DUBUQUE, IA 52001
(563) 583-9t21
Fax: (563) 556-4482
~Damage Asseses;I ~y: ~J~OHN Kt. OTZ JR.
Owner USA GREENWOOD
Address: 1925 JEFFERY DR DUBUQUE, IA 52001
Telephone: HomePhone: (563)588-9556
Mitchell Service.- 912492
Description: 1993 Chevrolet Lumina APV LS
Body Style: VanPess t09' WB
VIN: t GNDU06DOPTt51145
Drive Train: 3.1L Inj 6 Cyl 2WD
Ltee Emry Labor
Item Number Type Operation
L'me ttem
Description
Part
Par~ Number
Dollar Labor
Amount Units
I 205560 ~BDY REPAIR HOOD PAN_Et.
2 AUTO REF REFINISH HOOD OUTSIDE
3 205790 BDY REMOVE/REPLACE HOOD EMBLEM
4 AUTO REF ADD'L OPR CLEAR COAT
5 AUTO ADD'L COST PAINT/MATERIALS
6 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL
~Ex~-ting
10212753
GM PART
_O5*
C 2.7
t3.10 0.2
1.1
98.80 *
3.19'
* - Judgement item
C - Included in Clear Coat Calc
Add't
Labor Sublet
Labor Subtotals Units Rate Amount Amount Totals
Body 0.7 42.00 0.00 0.00 29.40 T
Refinish 3.8 42.00 0.00 0.00 159.60 T
TaXable Labor 189.00
Labor Tax ~ 6.000 % 1 t .34
Labor Summary 4-5 200.34
II. Part Replacement Summary
Taxable Parts
Sales Tax ~
Total Replacement Paris Amount
6.000%
13.t0
0.79
ESTIMATE RECALL NUMBER: 8/10/01 16:16:31 5309
UltrsMate is a Trademark of Mitchell Interna, tional
Mitchell Data Version: AUG 01 A Copyright (C) 1994 - 2000 Mitchell International
UitmMete Version: 4.7.507 All Rights Reserved
Page I
of 2
Date: 8/10101 04:t8 PM
Estimate ID: 5309
Estimate Version: 0
Preliminary
Prntile ID: Mitchell
itl. A~iona! Costs
Non-~axable Costs
Tnta{ Addittefl~l Go~ts
Ameu,t tV. Adjustn,,e~s
101.99 Customer Responsibility
101.99
I. Total Labor:.
II. Total Replacement Parts:
III. Total Additional Costs:
Gross Total:
IV. Tntal Adjusting:
Net Total:
This is a preliminary estimate.
Additional chanties to the estimate may be required for the actual repair.
PARTS PRICES AR~ SUBJECT TO CHANGE
.~etmt
0.00
200.34
13.89
101.99
316.22
0.~
316.22
ESTIMATE RECALL NUMBER~ 8/10101 t6:t6~$1 5309
UitmMate is a Trademad( of Mitchell International
Mitchell Date Version: AUG 0t A Copyright (C) 1994 - 2000 Mitchell Intsmat~ons!
UltraMate Version: 4.7.007 All Rights Rnserved
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